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Service Delivery Innovation Profile

County Health Department Enacts Systems-Based Changes in Primary Care Sites, Leading to Enhanced Access to Care and Improved Outcomes for HIV/AIDS Patients

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The Monroe County Health Department enacted a number of systems-based changes to improve access to routine and ongoing care for patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) being treated in three primary care sites. Changes include intensive patient tracking and outreach, flexible scheduling, engaging patients through self-management education and peer support, and renewed emphasis on having an annual comprehensive physical examination. The program increased the percentage of patients receiving routine care, improved health outcomes, and led to high levels of provider satisfaction.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of the frequency of clinic visits and key patient outcomes, including viral load and CD4 count, along with post-implementation anecdotal reports from providers.
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Developing Organizations

Monroe County Health Department
Key West, FLend do

Date First Implemented


Problem Addressed

HIV/AIDS continues to affect a significant number of individuals, particularly in certain geographic areas. Despite significant advances in treatment, as well as the growing availability of antiretroviral medications, many individuals living with HIV/AIDS do not regularly receive care for their disease, leading to poor health outcomes.
  • A large local concern: Monroe County, a small, tourism-driven county encompassing the Florida Keys, has an HIV/AIDS incidence that ranks among the highest in the country, with an estimated incidence of 804.1 cases per 100,000 residents in 2005.1 By comparison, the estimated incidence of HIV/AIDS across the United States was 12.3 cases per 100,000 people in 2006.2
  • Patients cycling in and out of care: Receiving ongoing care helps HIV/AIDS patients adhere to their medication regimen, which slows the progression of the disease and increases survival rates. However, many patients living with HIV/AIDS, particularly those who face multiple barriers to care (e.g., mental health concerns or increased social stigma), cycle in and out of care and are thus less likely to reap the benefits of treatment, including antiretroviral therapy.3,4

What They Did

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Description of the Innovative Activity

Monroe County Health Department enacted systems-based changes to improve access to routine and ongoing care for more than 350 patients with HIV/AIDS being treated in three primary care sites—a central clinic in Key West and two smaller outlying sites located 50 miles and 90 miles away. Changes included intensive patient tracking and outreach, flexible scheduling, engaging patients through self-management education and peer support, and renewed emphasis on having an annual comprehensive physical examination. Key elements of the program include the following:
  • Intensive patient tracking and outreach: To more efficiently gather and track patient information, the department implemented and adapted a client-level data system. Using this system, providers across Monroe County Health Department's three primary care sites receive monthly reports identifying patients with unmet needs who require followup. Department staff also use the data system to create regular reports listing patients with HIV/AIDS who have not been seen in 4 months, as well as any patients who have missed the window for their annual physical examination. The department collaborates with case managers from AIDS Help, Inc., a local AIDS service organization, to contact these patients by phone for followup support, resources, and rescheduling of appointments. Patients who cannot be reached by telephone receive followup letters by certified mail. County health department staff also use the data system to run reports of all patients who miss a scheduled appointment, following up with them by telephone to reschedule.
  • Increased clinic access and availability: To better accommodate patient needs, Monroe County Health Department makes open appointment slots available on a weekly basis. This change in scheduling practices ensures that new and newly diagnosed patients do not have to endure a lengthy wait to see a physician.
  • Self-management workshops led by staff, peers: Department staff and patients periodically hosted self-management workshops using the Stanford School of Medicine's Positive Self-Management Program for HIV. Staff members and patients cofacilitated these workshops, available to patients free of charge. Workshops covered various aspects of HIV/AIDS self-management, including adhering to medication regimens; maintaining appropriate nutrition and exercise habits; communicating with health professionals; and dealing with depression, frustration, and isolation. The workshops are currently not being offered owing to funding limitations; however, Monroe County Health Department is actively pursuing grants to reinstate them.
  • Patient self-management handbook: Department staff, with input and assistance from patients, produced a patient self-management handbook, entitled Staying Well With HIV. The handbook includes practical information on making and keeping medical appointments (including the importance of having an annual physical) and taking medications appropriately, along with contact information for relevant health professionals and other supportive services. All new patients with HIV/AIDS receive the printed handbook.
  • Emphasis on annual comprehensive examination: All clinic providers emphasize with patients the need for an annual comprehensive physical with a rectal examination. In addition, scheduling procedures for these examinations have been improved, and the department has trained providers and support staff on the use of new forms for gathering data during these examinations.

Context of the Innovation

Working in a small county with a relatively high rate of HIV/AIDS, Monroe County Health Department staff sought to enact changes that would improve care and outcomes for those suffering from the disease. Using a U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA) HIV/AIDS Bureau Ryan White grant, department staff participated in an Institute for Healthcare Improvement (IHI) collaborative that taught them how to institute systems-based changes swiftly and comprehensively. Although the formal partnership with IHI ended in 2002, many of the changes remain institutionalized within the organization's primary care sites.

The main clinic became a comprehensive primary care clinic in 2007. This transformation involved a change of location and the addition of many more patients being treated for conditions other than HIV/AIDS. Expanding the services provided at this clinic helped to reduce the stigma that had previously been associated with receiving HIV/AIDS treatment. Although the clinic faced challenges in caring for a larger number of patients with a wider variety of health concerns, the change helped to create an environment more conducive to improving outcomes for these patients.

Did It Work?

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The program increased the percentage of patients receiving routine care, improved health outcomes, and led to high levels of provider satisfaction.
  • More patients receiving routine care: At baseline, 85 percent of patients receiving care for HIV/AIDS were seen at least once every 3 months. By the end of 2001, this figure increased to 90 percent, and then to 91 percent in 2004 and to 94 percent in 2006.
  • Improved outcomes: At baseline, 26 percent of patients receiving care for HIV/AIDS had a viral load (the amount of HIV in the bloodstream) of less than 400, which indicates a relatively strong immune system. By 2004, this figure had increased significantly to 43 percent. Since that time, it has continued to increase, reaching 48.5 percent in 2006 and 79 percent by 2009. Between baseline and 2006, the percentage of patients with a CD4 count of more than 200 (another sign of a relatively strong immune system) remained steady at 75 percent. By 2009, that figure had risen to more than 80 percent.
  • Satisfied providers: Monroe County Health Department providers report being satisfied with the changes to their work processes; the use of client-level data has been singled out as being particularly useful, making it easy to identify and meet the needs of patients.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of the frequency of clinic visits and key patient outcomes, including viral load and CD4 count, along with post-implementation anecdotal reports from providers.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Obtaining funding: The department applied for and received a HRSA Ryan White grant to participate in the intensive IHI collaborative.
  • Creating core improvement teams: The Monroe County Health Department assembled a core improvement team, consisting of the HIV program director, a physician, and a nurse. This team attended IHI-sponsored learning sessions throughout the period of the grant. In addition, a group of key department staff and stakeholders met biweekly to discuss improvements, brainstorm ideas, and track progress. Those involved in these meetings included department leaders, a nurse, a member of the health support staff, a case manager from AIDS Help, Inc., and at least two clinic patients.
  • Participating in IHI collaborative: The core improvement team actively participated in the IHI collaborative, attending 2- to 3-week-long learning sessions per year during the period of the grant. The team communicated on an ongoing basis with an IHI expert consultant who offered technical assistance and support. In addition, the team provided IHI with periodic progress reports on its work; these reports were required under the terms of the grant.

Resources Used and Skills Needed

  • Staffing: All 20 county health department staff at the three primary care sites participated in implementing the systems-based changes designed to improve care to HIV/AIDS patients. In addition, one full-time quality manager handled grant-related followup, communicating with providers, and data management. As suggested above, members of the core improvement team dedicated a significant portion of their time and attention to this program during the IHI collaborative.
  • Costs: Currently, Monroe County Health Department spends approximately $1,500,000 each year on HIV/AIDS primary care. While participating in the IHI collaborative partnership, the total amount of their HRSA Ryan White grant was $548,500. Approximately $200,000 of that amount was budgeted for salaries to operate the primary care clinics and to conduct the quality improvement process. $40,000 was allocated at that time to support the full-time quality manager. A portion of the funding provided for travel expenses to participate in IHI learning sessions and continuing education opportunities. Funding also provided for salaries and equipment associated with information technology, which became more important as data collection and measuring outcomes became a routine part of clinic management.
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Funding Sources

Health Resources and Services Administration, HIV/AIDS Bureau; Ryan White CARE Act; Florida Department of Health
The HRSA Ryan White grant provided $548,500 in funding to support participation in the IHI collaborative.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Consider seeking outside training: Attending a conference or workshop on performance improvement or HIV/AIDS patient care can help to build staff enthusiasm and generate new ideas.
  • Test small changes: Rather than making sweeping changes to policies and procedures, start with several small changes and measure the results. Provide feedback to all involved, promoting staff buy-in.
  • Integrate changes into work processes: Avoid complaints about added work requirements by incorporating changes into staff's existing workflow. This approach should allow for a relatively easy transition, which will help in overcoming any staff resistance to change.

Sustaining This Innovation

  • Hire full-time quality manager: Maintaining system-wide improvement requires a dedicated staff member with sufficient time to devote to followup, feedback, communication with providers, and data management.
  • Keep enthusiasm for goals: Help staff maintain enthusiasm by continually integrating changes that benefit them as well as the patients.
  • Keep Chronic Care Model in mind: To meet and maintain goals, consider using the Chronic Care Model5 to make comprehensive and widespread changes. This model focuses on integrating improvements across the health system and the greater community and on cultivating relationships between informed and empowered patients and providers, supported by knowledge and resources.

More Information

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Contact the Innovator

Matthew Tochtenhagen
Quality Management Program Coordinator
1434 Kennedy Drive
Key West, FL 33040
(305) 293-3664

Innovator Disclosures

Mr. Tochtenhagen has not indicated whether he has financial interests or business/professional affiliations relevant to work described in this profile; however, information on funders is available in the Funding Sources section.


1 The Florida Division of Disease Control Surveillance Report (Hepatitis, HIV/AIDS, STD, and TB). Florida Department of Health; December 2006.
2 HIV/AIDS Surveillance Report, 2006. Centers for Disease Control and Prevention. Available at:
(If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
3 Rajabiun S, Mallinson RK, McCoy K, et al. "Getting me back on track": the role of outreach interventions in engaging and retaining people living with HIV/AIDS in medical care. AIDS Patient Care STDS. 2007;21(s1):S20-9. [PubMed]
4 Tobias C, Cunningham WE, Cunningham CO, et al. Making the connection: the importance of engagement and retention in HIV medical care. AIDS Patient Care STDS. 2007;21(s1):S3-8. [PubMed]
5 The Chronic Care Model Web site. Improving chronic illness care. Available at:
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Original publication: February 16, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: March 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: February 27, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.